Protocol: examining the effectiveness of an adaptive implementation intervention to improve uptake of the VA suicide risk identification strategy: a sequential multiple assignment randomized trial

Lisa A. Brenner,Katherine M. Dollar,Steven K. Dobscha,Jeri E. Forster,Nazanin H. Bahraini,Bridget B. Matarazzo,Catherine N. Barry,Edward P. Post

doi:10.1186/s13012-020-01019-6

Abstract

BackgroundIn 2018, the Veterans Health Administration (VHA) mandated implementation of a national suicide risk identification strategy (Risk ID). The goal of Risk ID is to improve the detection and management of suicide risk by standardizing suicide risk screening and evaluation enterprise-wide. In order to ensure continuous quality improvement (QI), ongoing evaluation and targeted interventions to improve implementation of Risk ID are needed. Moreover, given that facilities will vary with respect to implementation needs and barriers, the dose and type of intervention needed may vary across facilities. Thus, the objective of this study is to examine the effectiveness of an adaptive implementation strategy to improve the uptake of suicide risk screening and evaluation in VHA ambulatory care settings. In addition, this study will examine specific factors that may impact the uptake of suicide risk screening and evaluation and the adoption of different implementation strategies. This protocol describes the stepped implementation approach and proposed evaluation plan.MethodsUsing a sequential multiple assignment randomized trial (SMART) design, two evidence-based implementation strategies will be evaluated: (1) audit and feedback (A&F); (2) A&F plus external facilitation (A&F + EF). Implementation outcomes of interest include uptake of secondary suicide risk screening and uptake of comprehensive suicide risk evaluation (stages 2 and 3 of Risk ID). Secondary outcomes include rates of other clinical outcomes (i.e., safety planning) and organizational factors that may impact Risk ID implementation (i.e., leadership climate and leadership support).DiscussionThis national QI study will use a SMART design to evaluate whether an adaptive implementation strategy is effective in improving uptake of a mandated VHA-wide suicide risk screening and evaluation initiative. If this study finds that the proposed stepped implementation strategy is effective at increasing uptake and maintaining performance improvements, this approach may be used as an overarching QI strategy for other national suicide prevention programs.Trial registrationClinicalTrials.gov NCT04243330. Registered 28 January 2020

Highlights

In 2018, the Veterans Health Administration (VHA) mandated implementation of a national suicide risk identification strategy (Risk Suicide risk identification strategy (ID))
Secondary outcomes include rates of other clinical outcomes and organizational factors that may impact risk identification strategy (Risk ID) implementation. This national quality improvement (QI) study will use a sequential multiple assignment randomized trial (SMART) design to evaluate whether an adaptive implementation strategy is effective in improving uptake of a mandated VHA-wide suicide risk screening and evaluation initiative
If this study finds that the proposed stepped implementation strategy is effective at increasing uptake and maintaining performance improvements, this approach may be used as an overarching QI strategy for other national suicide prevention programs

Summary

Introduction

In 2018, the Veterans Health Administration (VHA) mandated implementation of a national suicide risk identification strategy (Risk ID). The objective of this study is to examine the effectiveness of an adaptive implementation strategy to improve the uptake of suicide risk screening and evaluation in VHA ambulatory care settings. This study will examine specific factors that may impact the uptake of suicide risk screening and evaluation and the adoption of different implementation strategies. The Department of Veterans Affairs (VA) has made significant strides in suicide prevention, for veterans receiving Veterans Health Administration (VHA) care. Most of these efforts have focused on downstream interventions to reduce suicidal behavior among those already identified to be at high risk. The three stages include two levels of screening, followed by a comprehensive suicide risk evaluation (CSRE) (Fig. 1)

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